Clinic shift changes are approved ONLY due to special circumstances. All changes must be requested at least 72 hours in advance and approval of changes will be at the sole discretion of the Clinic Supervisor. Once this form is received the Clinic Supervisor will review the schedule for any conflicts and confirm with both students before the change is determined to be final.

* Required

Date *

MM

/

DD

/

YYYY

Your Name *

Your answer

Originally Scheduled Shift *

MM

/

DD

New Shift *

MM

/

DD

Replacement Student Therapist Name *

Your answer

Originally Scheduled Shift *

MM

/

DD

New Shift *

MM

/

DD

Reason for Request *

Your answer

I understand that submission of this form does not constitute a schedule change and that all changes are at the sole discretion of the Clinic Supervisor. *